MUSCULOSKELETAL SURGERY最新文献

{"title":"Comparison between early versus delayed (staged) plate fixation in the treatment of pilon (tibial plafond) fractures: a systematic review and meta-analysis.","authors":"M M Siddig, M H J Amin, M Y M Eldouma, Leina Elomeiri, Sakshi Kumari, J H J Amin, M A Eltayeb, Ashir Kanwal","doi":"10.1007/s12306-026-00963-8","DOIUrl":"https://doi.org/10.1007/s12306-026-00963-8","url":null,"abstract":"<p><p>The optimal timing of definitive fixation for tibial plafond (pilon) fractures remains controversial. While staged protocols aim to reduce soft-tissue complications, early definitive fixation may reduce morbidity associated with prolonged external fixation. This systematic review and meta-analysis evaluated whether early fixation is associated with different complication rates compared with delayed or staged management. A systematic search of PubMed, Web of Science, Scopus, and the Cochrane Library was conducted from inception to December 2025. Comparative studies evaluating early versus delayed or staged surgical management of adult pilon fractures were included. Early management was defined as definitive plate fixation performed within 48-72 h after injury, while delayed or staged management involved initial external fixation followed by delayed definitive surgery. Primary outcomes were infection or wound complications and reoperation. Secondary outcomes included malunion and nonunion. Random-effects meta-analyses were performed using risk ratios (RR) with 95% confidence intervals (CI). Risk of bias was assessed using validated tools, and certainty of evidence was graded using GRADE. Reporting followed PRISMA 2020 guidelines. This review was not prospectively registered. Seven studies involving 543 patients were included. There was no significant difference in infection or wound complications between early and delayed or staged fixation (RR 0.83; 95% CI 0.41-1.69). No significant reduction in reoperation was observed with early fixation (RR 0.60; 95% CI 0.36-1.00). No significant differences were found for malunion (RR 0.92; 95% CI 0.24-3.54) or nonunion (RR 0.79; 95% CI 0.49-1.28). Overall certainty of evidence ranged from low to very low. Early definitive plate fixation appears to have comparable complication rates to delayed or staged protocols, with a possible reduction in reoperation. Selective early fixation may be safe in appropriately chosen patients.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148369344","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lessons from the learning curve of the direct anterior approach in total hip arthroplasty: a systematic review.","authors":"Nicola Corradi, Alberto Trimarchi, Federica Manca, Ilaria Martini, Andrea Colombelli, Alberto Belluati","doi":"10.1007/s12306-026-00961-w","DOIUrl":"10.1007/s12306-026-00961-w","url":null,"abstract":"<p><p>The direct anterior approach (DAA) in total hip arthroplasty (THA) offers advantages in muscle preservation and early recovery but is challenged by a steep learning curve that may affect outcomes. This systematic review analyzed complication and reoperation rates during the learning phase of DAA in primary THA. A comprehensive search of PubMed, Cochrane Library, and Web of Science, was performed according to PRISMA guidelines. Studies reporting complications and reoperations during the DAA learning curve were included. Data on demographics, surgical volume, and adverse events were extracted. The primary outcomes were complication and reoperation prevalence with 95% confidence intervals (CI). Thirty-five studies encompassing 96,605 primary THAs met inclusion criteria. The overall complication prevalence during the learning curve was 2.75% (2,653/96,605; 95% CI: 2.65%-2.85%). The most frequent complications were aseptic loosening (22%), periprosthetic fracture (14%), dislocation (10%), and prosthetic joint infection (9%). The reoperation prevalence was 1.81% (1,743/96,605; 95% CI: 1.72%-1.90%), mainly due to aseptic loosening, infection, and fracture. Heterogeneity in surgeon experience and reporting limited comparability across studies. The adoption of DAA in THA is associated with a measurable learning curve characterized by increased complication and reoperation rates during early experience. Awareness of these risks, along with structured training and careful patient selection, is essential to mitigate early failures. Further prospective studies are needed to better define the learning curve threshold and standardize outcome reporting.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148360803","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gait analysis after TKA: Do different alignment strategies lead to different outcomes? A systematic review.","authors":"B D Bulzaki Bogucki, V Digennaro, A Panciera, D Cecchin, R Ferri, L Benvenuti, C Faldini","doi":"10.1007/s12306-026-00959-4","DOIUrl":"https://doi.org/10.1007/s12306-026-00959-4","url":null,"abstract":"<p><strong>Background: </strong>Total knee arthroplasty (TKA) provides reliable pain relief and implant survival; however, a clinically relevant proportion of patients still report residual symptoms, functional limitations, or an unnatural joint perception. Instrumented gait analysis may objectively assess postoperative function and clarify whether alignment strategies influence gait recovery.</p><p><strong>Methods: </strong>This systematic review followed PRISMA 2020 recommendations. PubMed/MEDLINE and the Cochrane Library were searched from January 1990 to November 2024. Eligible studies reported instrumented gait-analysis outcomes after primary fixed-bearing TKA performed with mechanical, kinematic, anatomical, functional, inverse kinematic, restricted kinematic, or other personalized alignment techniques, with at least 12 months of follow-up. Revision TKA, unicompartmental knee arthroplasty, case reports, reviews, and studies without an appropriate comparison group were excluded.</p><p><strong>Results: </strong>Six studies met the inclusion criteria, underscoring the limited available evidence. The studies were heterogeneous in design, alignment strategy, gait-analysis protocol, and reported outcomes. Four studies compared kinematic and mechanical alignment, one inverse kinematic and adjusted mechanical alignment, and one gap-balanced TKA with healthy controls. No consistent gait advantage of one alignment strategy was demonstrated. Some studies reported lower knee adduction moment or gait patterns closer to healthy controls after kinematic or inverse kinematic alignment, but findings were inconsistent.</p><p><strong>Conclusion: </strong>Evidence on gait analysis after TKA with different alignment strategies remains limited and heterogeneous. Current data do not allow firm conclusions regarding the superiority of any alignment strategy. Larger prospective studies using standardized gait-analysis protocols are needed.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-06-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148212000","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Total knee arthroplasty alignment strategies and their impact on ankle and hindfoot: a systematic review.","authors":"Bartolomiej Dobromir Bulzaki Bogucki, Vitantonio Digennaro, Alessandro Panciera, Davide Cecchin, Riccardo Ferri, Lorenzo Benvenuti, Cesare Faldini","doi":"10.1007/s12306-026-00958-5","DOIUrl":"https://doi.org/10.1007/s12306-026-00958-5","url":null,"abstract":"<p><p>Multiple alignment strategies have been proposed in total knee arthroplasty (TKA), ranging from systematic approaches such as mechanical alignment and anatomical alignment to personalized techniques including kinematic, restricted kinematic, inverse kinematic, and functional alignment. Although previous studies and reviews have evaluated the relationship between TKA and distal alignment, the influence of different knee alignment strategies on ankle and hindfoot alignment remains less clearly defined. The aim of this systematic review was to evaluate the impact of TKA alignment strategies on postoperative ankle and hindfoot alignment. A systematic review was conducted according to PRISMA guidelines. Medline (PubMed) and the Cochrane Library were searched for studies evaluating preoperative and postoperative ankle and/or hindfoot alignment following TKA. Eligible studies included clinical investigations reporting radiographic measurements of the ankle or hindfoot and clearly defining the TKA alignment strategy adopted. Study design, level of evidence, patient demographics, alignment technique, radiographic parameters, and functional outcomes were extracted and analyzed. Twenty-two studies were included, most of which provided level III evidence. Sixteen studies evaluated mechanically aligned TKA only, five compared mechanical alignment with personalized or alternative alignment strategies, and one investigated a personalized alignment strategy without direct comparison. Mechanical alignment consistently corrected coronal knee malalignment, particularly varus knee deformity, but distal ankle and hindfoot adaptations were variable. These changes appeared to be influenced by the severity of preoperative varus deformity, subtalar joint flexibility, and the presence of ankle osteoarthritis. Residual hindfoot valgus and incomplete distal compensation were frequently reported, especially in patients with severe preoperative varus knee deformity. Mechanical alignment reliably corrects coronal knee alignment, but ankle and hindfoot responses are variable and may remain incomplete in patients with severe varus deformity, ankle osteoarthritis, or limited subtalar compensation. Selected studies suggest that personalized alignment strategies may reduce compensatory distal changes, but the available evidence is limited and heterogeneous. Further comparative studies with standardized ankle and hindfoot assessment are needed before firm conclusions can be drawn.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148199524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Robotic-assisted anterior and posterior cervical spine surgeries.","authors":"M Pai, V Srinivasa, A Soni, B Thirugnanam, A Kashyap, A Vidyadhara, S K Rao","doi":"10.1007/s12306-025-00918-5","DOIUrl":"10.1007/s12306-025-00918-5","url":null,"abstract":"<p><strong>Introduction: </strong>Cervical spine surgeries pose unique challenges due to the proximity of critical structures and limited visualization with traditional techniques. Robotic assistance offers potential solutions by providing precise navigation and reducing radiation exposure. We present a series of 30 consecutive patients undergoing various cervical spine procedures utilizing the MazorX Stealth Edition (MXSE) robotic system with intraoperative imaging.</p><p><strong>Methods: </strong>Anterior and posterior surgeries were performed using the MXSE system. Surgical parameters, implant placement accuracy, and patient outcomes were assessed. Data analysis included anthropometric measurements, surgical times, blood loss, radiation exposure, and patient-reported outcomes.</p><p><strong>Results: </strong>Mean age was 52.43 years, with 43.33% females. Procedures included anterior cervical discectomy and fusion, corpectomy, disc replacement, and posterior decompression and fusion. Implant placements were accurate, with no neurological deficits or reoperations. Surgical parameters were comparable to standard techniques.</p><p><strong>Discussion: </strong>Robotic assistance offers accurate implant placement and reduced radiation exposure. Challenges such as vertebra segmentation and surgical approach were addressed. Further research and instrument development are needed for wider adoption.</p><p><strong>Conclusion: </strong>Robotic navigation in cervical spine surgeries enhances precision and safety. Continued advancements in technology and technique are essential for broader implementation.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":"199-204"},"PeriodicalIF":0.0,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144961840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Surgical management of spinal ochronosis: A case series of surgical interventions and outcomes.","authors":"M Chehrassan","doi":"10.1007/s12306-025-00930-9","DOIUrl":"10.1007/s12306-025-00930-9","url":null,"abstract":"<p><strong>Study design: </strong>A retrospective case series of 4 patients with spinal ochronosis.</p><p><strong>Objective: </strong>To evaluate the clinical, radiological, and surgical outcomes in patients with spinal ochronosis undergoing surgical intervention. Ochronosis, resulting from alkaptonuria, leads to homogentisic acid deposition in connective tissues, affecting the spine early. Due to its rarity, limited literature addresses the clinical, radiological, and surgical aspects of spinal ochronosis.</p><p><strong>Methods: </strong>We reviewed four cases of spinal ochronosis where patients underwent surgery for symptoms such as pain, paresthesia, and myelopathy. Radiological findings, intraoperative observations, and postoperative outcomes were analysed. The iOS 'Measure' app was used to quantify angles intraoperatively.</p><p><strong>Results: </strong>Patients, aged 45-56, presented with leg pain, paresthesia, and gait disturbances. Radiographs revealed disc degeneration, spinal stenosis, and sagittal imbalance. Surgical interventions included decompression, fusion, and en bloc resection of calcified ligamentum flavum. Dural tears occurred in 2 cases but were successfully repaired. All patients experienced significant symptom relief, though residual sagittal imbalance persisted in some.</p><p><strong>Conclusions: </strong>Spinal ochronosis presents significant surgical challenges due to tissue fragility, adhesions. Surgical intervention can provide symptom relief, however, complete correction of deformities may not always be feasible. Further research is required to optimize treatment strategies for this rare condition.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":"205-211"},"PeriodicalIF":0.0,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145401392","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Revisiting the role of bone grafting in scaphoid fixation with volar plates: a multivariable analysis.","authors":"Salvador J Gomez Bermudez, Jaime A Londoño Restrepo, Miguel A Gómez Trillos, Laura X Ramírez Carmona, Rafael F Galindo Zuluaga, Ruben D Arias Perez, Daniela Carmona Cano, Sebastian Calle Diaz, Santiago Tobon Orrego","doi":"10.1007/s12306-025-00926-5","DOIUrl":"10.1007/s12306-025-00926-5","url":null,"abstract":"<p><strong>Purpose: </strong>To evaluate the radiographic and functional outcomes of scaphoid fractures and nonunions treated with volar locked plate fixation, with or without autologous bone grafting, and to explore whether graft use was associated with improved consolidation or function.</p><p><strong>Methods: </strong>This retrospective cohort study included 19 adult patients who underwent surgical treatment with volar anatomical plates for scaphoid fractures or nonunions. Radiographic union was assessed at 3, 6, and 12 months. Functional outcomes were measured using the QuickDASH score preoperatively and at 12 months postoperatively. Graft use was determined intraoperatively based on defect characteristics. Statistical analyses included non-parametric tests and multivariable models.</p><p><strong>Results: </strong>The mean patient age was 24.5 ± 5.4 years, and 94.7% were male. Scaphoid nonunion was present in 11 patients (57.9%), and autologous bone grafting was performed in 15 (78.9%). Radiographic consolidation was achieved in 94.7% of cases at 12 months. QuickDASH scores improved significantly (mean change: 20.6 points; p < 0.001). There were no significant differences in union or functional outcomes between grafted and non-grafted patients (p = 1.000 and p = 0.115, respectively). Interestingly, patients with nonunions demonstrated significantly better postoperative function than those with acute fractures (p = 0.034), although this did not exceed the minimal clinically important difference. Multivariable analysis failed to identify predictors of union or function, explaining only 37% of the variance.</p><p><strong>Conclusion: </strong>Volar locked plate fixation provides high union rates and significant functional improvement in scaphoid fractures and nonunions. Bone grafting did not confer additional benefit, supporting selective rather than routine use. Further studies are warranted to clarify prognostic factors and optimize treatment strategies.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":"233-239"},"PeriodicalIF":0.0,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13241431/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145182180","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sarcopenia: current state of knowledge and its implications in orthopaedics and traumatology for enhanced clinical strategies and patient outcomes.","authors":"Niccolò Stefanini, Alberto Di Martino, Matteo Brunello, Manuele Morandi Guaitoli, Chiara Di Censo, Giuseppe Geraci, Federico Pilla, Cesare Faldini","doi":"10.1007/s12306-025-00923-8","DOIUrl":"10.1007/s12306-025-00923-8","url":null,"abstract":"<p><strong>Introduction: </strong>Sarcopenia is a pathologic condition frequent in aged population, leading to functional and cognitive impairment. Given the ageing of the population worldwide, the topic has generated interest in the last decades and is expected to be more relevant in the near future. This paper aims to present the mechanism of sarcopenia, the current state of knowledge regarding diagnosis and treatment and the role of sarcopenia in orthopaedic and traumatological settings. Sarcopenia is an age-related condition which overlaps with other features of frailty syndrome by similar biochemical pathways. It is characterized by a loss of muscle mass and function, mainly due to reduced anabolism. The importance of prompt diagnosis is highlighted; however, there is a lack of standardized cut-offs, thus affecting also non-pharmacological and pharmacological therapeutic options, which are not well defined. The increased risk of falls, disability, cognitive impairment and association with osteoporosis exacerbates fracture risk. Post-surgery inactivity contributes to sarcopenia, which also leads to prolonged hospital stays, increased complications and worse clinical outcomes.</p><p><strong>Conclusion: </strong>Ageing of population will increase chronic-related conditions. Sarcopenia is a growing and still largely unexplored clinical challenge. Research should focus on diagnostic thresholds and therapeutic protocols to promote interdisciplinary assessment and targeted interventions. In the orthopaedic field, attention ranges from the prevention of fragility fractures to proper perioperative management.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":"127-138"},"PeriodicalIF":0.0,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145023851","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Anterior femoral notching during total knee arthroplasty: a predictor of periprosthetic femoral fractures?","authors":"V Benkovich, A Abialevich, B Schebenkov, I Tzaytlin, M Fiterman, A Aronskind, A Benshtein","doi":"10.1007/s12306-025-00927-4","DOIUrl":"10.1007/s12306-025-00927-4","url":null,"abstract":"<p><strong>Introduction: </strong>Anterior femoral notching during TKA is thought to weaken the distal femur, potentially increasing periprosthetic fracture risk, but its clinical impact remains debated. This study examines whether notching independently predicts such fractures and assesses related clinical outcomes using the Tayside classification system for cortical violations.</p><p><strong>Methods: </strong>A retrospective cohort study was conducted on 715 patients who underwent primary TKA. Patients were divided into Group 1 without notching (control group) and Group 2 with any presence of notching according to Tayside classification system, which assesses cortical violations based on the extent of involvement. Fracture incidence and additional multivariate analysis were used to control for confounding factors, including bone quality (presence of osteoporosis) and demographics.</p><p><strong>Results: </strong>PPFs were significantly more frequent in the notching group (2.67%) than in the control group (0.24%) (p < 0.01). Despite 6.68% of patients having osteoporosis, no correlation with PPFs was found. All fractures occurred in female patients due to falls. A cortical defect > 2.5 mm was a potential predictor of femoral weakness, with larger defects in the notching group (2.20 ± 0.54 mm) vs. control (0.02 ± 0.16 mm), p < 0.01. PPF incidence was 1.33% for Grade 1 and 2 defects and 0.33% for Grade 3 defects.</p><p><strong>Conclusion: </strong>Preventive strategies, including meticulous surgical technique and tailored postoperative rehabilitation, are essential to minimize PPF risk. Anterior femoral notching compromises femoral integrity, with defects > 2.5 mm significantly increasing fracture risk. Careful surgical planning, especially in patients with poor bone quality or advanced age, is crucial to optimize outcomes and reduce complications.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":"213-217"},"PeriodicalIF":0.0,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145058588","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk factors for cephalic necrosis after plate and screw osteosynthesis of 3- and 4-part proximal humerus fractures: prospective cohort study of 121 patients.","authors":"Gianluca Canton, Noemi Zaffaroni, Dario Ghassempour, Andrea Marchetti, Antongiulio Favero, Alex Buoite Stella, Gioia Giraldi, Chiara Ratti, Belinda Trobec, Luigi Murena","doi":"10.1007/s12306-025-00920-x","DOIUrl":"10.1007/s12306-025-00920-x","url":null,"abstract":"<p><strong>Purpose: </strong>Avascular necrosis (AVN) of the humeral head is a relatively frequent complication after proximal humerus fractures (PHF), often leading to poor outcomes and reoperation. This study investigates both non-modifiable (fracture type, trauma energy, age, sex, Charlson comorbidity index) and modifiable (surgical access, bone graft use, reduction quality) risk factors for post-operative AVN in Neer 3-4-part PHFs.</p><p><strong>Methods: </strong>Patients with Neer 3-4-part PHFs treated using angular stable plates and followed for at least 6 months were included. Clinical and radiographic elements were evaluated. Statistical analysis was performed with SPSS 26, evaluating the data by both descriptive and univariate analyses.</p><p><strong>Results: </strong>Among 121 patients (mean age 63, mean follow-up 10.1 months), 8 developed AVN (6.6% incidence). Only 50% of AVN cases occurred within the first 15 months of follow-up. AVN was significantly associated with 4-part fractures (p = 0.050), medial hinge disruption (p = 0.022), tuberosity comminution (p = 0.003), failure to restore the cervico-diaphyseal angle (p = 0.022), and residual varus/valgus deformity (p = 0.01). The presence of a bone graft suggested a fourfold-increased risk of AVN (OR = 4.219).</p><p><strong>Conclusions: </strong>The present study confirms that the risk of necrosis is predicted by the type of fracture, as well as by the quality of fixation. Age, sex and CCI of the patient, varus/valgus fracture displacement, glenohumeral dislocation and energy of the trauma did not suggest the risk of AVN. These findings underscore the importance of meticulous surgical techniques to address these factors and potentially reduce the incidence of AVN.</p><p><strong>Level of evidence iii: </strong>Prospective cohort study.</p>","PeriodicalId":18875,"journal":{"name":"MUSCULOSKELETAL SURGERY","volume":" ","pages":"183-189"},"PeriodicalIF":0.0,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13241432/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144961812","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}